Inside a Colic Clinic

Difficult to define, even harder to treat, colic can turn a family's life upside down. In Rhode Island, one center is paving the way for new thinking about how to treat crying babies and the parents who are desperate to help them.
By Tracy Mayor

Introduction, p.1

Delaney Sullivan is fast asleep in her car seat. All of 2 months old, she doesn't wake on a recent Tuesday afternoon as her mother and grandmother are buzzed through the foyer at the Brown Center for the Study of Children at Risk in Providence. In the spacious, sunlit, and at that moment, hushed waiting room, the receptionist greets them by name and peeks over her desk at Delaney. Her mom removes the baby's hat, revealing peach-colored fuzz that causes everyone to coo, but Delaney doesn't stir.

The irony is supreme. Delaney is a patient at the Infant Behavior, Cry and Sleep Clinic, better known as the Colic Clinic, a collaboration between Brown University/Brown Medical School and Women & Infants Hospital of Rhode Island. At 3 weeks old, Delaney started to exhibit signs of colic, the newborn condition characterized by sudden, intense, inconsolable bouts of crying; disordered feeding; and difficulty sleeping. During the day, she'd grunt, fuss, and cry; in the evening, she sobbed for seemingly endless intervals. "My very happy baby turned into a very unhappy baby," says her mom, Athena Sullivan, 33, of Warwick, RI, who works as a school psychologist at Attleboro High School in Massachusetts.

When she wasn't crying outright, Delaney was so fussy and agitated that Sullivan felt she had to rock, shush, and walk her nonstop to keep her from screaming again. Delaney rarely napped, wasn't sleeping well at night, and often seemed to be in genuine pain, especially after a feeding session.

After unproductive discussions with their pediatrician, the Sullivans sought out the services of the Colic Clinic. With more than 270 patients per year, most from New England but some from beyond, the clinic sees families who find it through healthcare professionals, mothers' groups, desperate Internet searches, or word of mouth. What draws these families? Quite simply, the clinic's revolutionary, research-backed approach: It treats excessive crying in infants not just by investigating what's bothering the baby but by tending to the psychological needs of the child's beleaguered parents as well.

During this visit, Sullivan makes two insurance co-payments—one for one of the clinic's two pediatricians, billed to the baby's account, and another for one of the clinic's psychologists or social workers, billed to her parents' account. Soon, Delaney is surrounded by four women—her mom; her grandmother; Pamela High, M.D., a pediatrician and the medical director of the clinic; and Jean Twomey, Ph.D., a social worker. Behind a darkened window in one wall of the examining room is an observation area, complete with video cameras, recorders, and microphones, where two other people, graduate students of Dr. High's, watch the proceedings.

For the next 20 minutes, Sullivan talks almost without taking a breath, chronicling every aspect of Delaney's days and nights since their last visit two weeks ago. Drs. High and Twomey listen intently, taking notes and nodding sympathetically. The clinicians then study timesheets on which Sullivan had tracked Delaney's fussing, crying, eating, and sleeping over three recent days and nights, with details about where Delaney had fallen asleep (her swing, her car seat, her crib, her parents' arms).

Now Dr. Twomey spreads out Delaney's "cry diary" on the floor, with fussing and crying episodes highlighted in fluorescent green and yellow. A quick glance shows plainly that the Sullivans had a miserable day the previous Saturday, with hour upon hour filled with either F's or C's.

"I can see from the chart this must have been a very difficult day," Dr. Twomey says gently. "When I see all those F's, I think you must have been working hard then to keep her from crying, yes?" Sullivan nods, her deep brown eyes threatening to tear up.

As the appointment winds down two hours later, Sullivan wakes Delaney to be weighed and measured, and at last the baby starts to produce some of the hoarse, unmistakable cries of colic. "Here we go," says Sullivan, rolling her eyes as she jiggles Delaney on her shoulder.

But she's able to smile. Not only had she been given an enormous chunk of undivided attention from top pediatric specialists, she's also received a three-page printout summarizing the progress she's made and detailing strategies and goals for Delaney's sleeping and feeding regimens over the next two weeks. Most important, Sullivan leaves with the conviction that she can do something about her baby's colic—perhaps the most noteworthy prescription the Colic Clinic dispenses.

A Radical Approach, p.2

To define and diagnose colic, doctors have long used the "rule of three," first developed by pediatrician Morris Wessel, M.D., in 1954: at least three hours of crying a day for at least three days per week over a period of three weeks or more. Frustrated parents, meanwhile, tend to define colic by what it's not—not hunger, not a wet diaper, not fussing, not like other babies, and definitely, absolutely not normal.

People will often tell parents who come to the clinic, "Oh my baby had colic, it's so common," says Dr. Twomey, who's also an assistant professor of psychiatry and human behavior at Brown Medical School. "But these parents know there's something qualitatively different about their experience."

Barry Lester, Ph.D., the director of the Brown Center for the Study of Children at Risk and founder of the clinic, has pinpointed more specific characteristics of colic, culled from scientific research conducted there and elsewhere. A baby has colic if her crying episodes have a sudden onset; if the cry is high-pitched and intense; if she exhibits physical signs of discomfort, such as pulling her legs to her chest, doubling over, tightening the muscles in her arms and legs, clenching her fists, or holding her breath; and if she is inconsolable, meaning that she seems unable to respond to her parents' attempts to soothe her.

Because there's no cut-and-dried diagnosis for colic, there's no standard cure for treating it, says Dr. Lester. "There are colleagues of mine who think it's a waste of time to study colic because it's just a variation on normal development," says Dr. Lester, the author of Why Is My Baby Crying? "Oftentimes I'll say to those people, 'Have you ever talked to parents who have gone through this?'"

Dr. Lester has. Since founding the clinic in 1986, he and his colleagues have operated on the theory that an intensive, multifaceted approach to helping colicky infants, one that addresses both hurting babies and their weary family members, helps reduce tears in a way that no other approach could. "The departure we've made is to think about not just the baby but about how the crying impacts the whole family," explains Dr. Lester.

In other words, they take colic seriously. "A lot of pediatricians think the problem is complaining, irritating mothers who can't deal with their babies' crying, but we have evidence these babies are in pain," says Dr. Lester, citing a study done at the clinic that found that the cries of a baby with colic are acoustically similar to those of a baby in pain. "We acknowledge and legitimize parents' issues and feelings about their baby's crying."

There's evidence that the clinic's approach works. In a recent study of 71 families led by a team from the Brown Center for the Study of Children at Risk, babies receiving family-based care showed a decline in colic symptoms and an increase in feeding efficiency and time spent awake and content. And their mothers reported an improvement in depression symptoms as well. Babies started treatment between 4 and 8 weeks of age; within six weeks, their crying decreased by an average of 60%, compared to a 40% reduction in infants who got standard pediatric care.

Those findings constitute a compelling argument against the conventional pediatric treatment that often takes a "wait it out" approach to colic. "It's not useful to tell parents who are struggling to get through a day that this is an experience that will pass in a matter of weeks or months," says Dr. Twomey.

Pinpointing The Problem, p.3

Over the years, Dr. Lester has amassed a collection of commercial colic "cures," none of which he believes work to address true colic. Displayed prominently in his office at the clinic, they include white-noise machines, CDs of a mother's heartbeat, vibrating baby seats, aromatherapy oils, and from England, commercially packaged Gripe Water (the original homemade recipe calls for dill oil, sodium bicarbonate, and 3% to 5% alcohol—do not try this at home).

Along with these over-the-counter products, certain colic-soothing techniques have been used by multiple generations of parents. While putting a baby in his carrier on top of a running clothes dryer or turning on the vacuum cleaner or shower to soothe him to sleep isn't likely to cause harm, it won't quiet a truly colicky baby for more than a short period of time, says Dr. Lester.

Other myths about the condition are more toxic, to both babies and parents, Dr. Lester says. Contrary to popular belief, colic isn't inherited and isn't caused by genetics, isn't more common in boys or firstborn babies, isn't caused by bad parenting, and isn't untreatable.

So how does the clinic treat its young patients? According to research done there and elsewhere, babies with colic nearly always have an interrelated set of feeding, sleep, and stimulation problems. On the medical side, the clinicians' goal is to unravel those interdependencies, decide which symptoms to treat first and how, and prescribe behavioral changes to address the remaining issues.

Typically, feeding problems are the first item on the agenda, says Dr. High, simply because babies won't thrive if they're not eating well. In a 2004 study, researchers at the clinic found that when they submitted two groups of infants to abdominal ultrasound, babies with colic were more likely to exhibit a wide range of feeding difficulties. Their problems included disorganized feeding behaviors, less-rhythmic sucking, and GER—the condition in which milk and gastric acid flow back up out of the stomach into the baby's esophagus, causing pain and, often, excessive spitting up—and its chronic manifestation, gastroesophageal reflux disease, or GERD.

Other studies indicate that some babies with colic may suffer from food allergies. When Jeannette Levenstein, M.D., a Los Angeles-based pediatrician not affiliated with the Colic Clinic, analyzed the stools of babies in her practice who seemed in distress, she discovered that many samples contained microscopic amounts of blood, an indication of allergic colitis. The informal study found that as many as 75% of crying infants in Dr. Levenstein's practice had GER, an intolerance to the protein found in lactose and/or soy, or both conditions.

Feeding-related treatments the clinic prescribes can include, for GER or GERD babies, thickening the formula with cereal and prescribing medications like Zantac, which reduces the amount of acid the stomach produces (measures that should only be taken in consultation with a physician, notes Dr. High). Other treatments include changing to hypoallergenic formula or eliminating certain foods from breastfeeding women's diets. Behavioral changes can help eliminate disordered feeding habits like "grazing"—that is, feeding every hour or so—which can cause some babies to cry or sleep poorly because they never feel full. Finally, keeping the baby upright for 20 to 30 minutes after eating, using wedge pillows, and propping up the crib mattress can help GER babies, who are often in pain when they lie flat after a feeding.

On the sleep side of the equation, while many newborns experience typical day-night confusion with little fussiness, others, for reasons that still aren't fully understood, react with bouts of inconsolable crying. Indeed, it's not unusual for babies at the Colic Clinic to have their difficulties with crying and GER resolved but continue to have sleep difficulties, Dr. Twomey says.

For those infants, Colic Clinic doctors recommend schedules, routines, and the encouragement of self-soothing techniques. Parents are advised to help their babies form solid sleep associations by establishing a consistent, calming bedtime routine even for the youngest infants and later using a shortened version of the same routine for daytime naps. That means making nighttime feedings all business, with low lights and minimal talking; using the same place for day and night sleeping; and putting the baby down when awake but drowsy.

Do these strategies make a difference? Yes, absolutely, says Tiffany Munro, 36, a Harrisville, RI, mother of twins. Munro's daughter, Amelia, was an easy baby—she slept and ate happily and cried only when she was hungry or her diaper needed changing. Amelia's twin brother, Blake, was another story. He cried more than other babies in the hospital when born and cried excessively after Tiffany and her husband, Chris, brought him home. "It wasn't a cranky cry, it was a cry of severe pain," recalls Tiffany. "He would grab at our chest as if saying, 'I'm in pain, please help me.'"

On the advice of the twins' pediatrician, the Munros switched formulas, perhaps six times in total, tried over-the-counter anti-gas drops, and put Blake on Zantac (but took him off when it didn't appear to make a difference). Blake wouldn't sleep unless held, which was difficult enough with twins but impossible for Tiffany by herself once Chris went back to work.

Sometimes, visitors would say, "I'll hold the good baby," meaning Amelia. "I'd think, Blake's not a bad baby, he's just crying," says Tiffany. "I'd sit and cry with him. I was a new mom, I wanted what was best for him, and I knew something was wrong. I just wanted somebody to give us some answers."

Finally, Blake's doctor suggested the Colic Clinic. Tiffany spent 30 minutes on the phone with Cynthia Miller-Loncar, Ph.D., a clinic psychologist, and got an appointment within 48 hours. Before she hung up, Dr. Miller-Loncar said, "I think we can help you."

Blake was diagnosed with GER, put back on Zantac, and prescribed changes to his environment (his parents held him upright after eating and put a wedge under his head in his crib) and to his feeding and sleep routines. Within three weeks, "he was sleeping 100% better," says Tiffany. "He was still having crying fits, but they were much less severe." Now 10 months old, Blake is a good eater and sleeper, and his mother is grateful they got help when they needed it.

Parent As Patient, p.4

After each visit, parents like Athena Sullivan and Tiffany Munro leave the clinic not just with a sheaf of instructions, but with a sense they aren't losing their minds. That's by intention: Validation of parents' difficulties is key to effective colic treatment, says Dr. Twomey.

"Mothers think they're having too much difficulty coping," she says. "From the first meeting, I try to say colic is not typical. If you were sitting where I'm sitting, you'd be quite amazed at how well you're functioning."

Dr. Twomey and her colleagues often write up "prescriptions" instructing moms to take an hour each day away from their crying babies or go out alone with their husbands once a week. All parents who visit the clinic are asked if they ever have any thoughts about harming their babies; whether they're exhibiting any signs of depression; if they have relatives, friends, or caregivers to help with their babies; and what they're doing to care for themselves physically and emotionally.

One reason the clinic is committed to family-based treatment, says Dr. Lester, is that unaddressed colic can sometimes cause rifts within the family later on. A couple's marriage can be strained, or mothers can develop a pattern of interaction with their child that's either too distant or too close. Ramifications can continue into the toddler years and beyond, says Dr. Lester.

There's also the danger of maternal depression. In a 2006 study, researchers led by Dr. High discovered a strong correlation between women who reported symptoms of postpartum depression and those who said their babies were inconsolable. What's not yet been established, Dr. High says, is whether depressed moms somehow cause or exacerbate their babies' crying, or if all that crying causes maternal depression.

Either way, it's a dangerous double-whammy when a depressed mother is caring for a colicky infant. "For us, it's not so much about when is the baby going to stop crying, it's more about what damage has been done to the parent-child relationship and how that damage can be repaired," Dr. Lester explains.

Attention to both mother and baby was exactly what Vickie Raposo of Fall River, MA, needed last winter. Her husband, Gershon, who's in the army and assigned to Operation Iraqi Freedom, came home for 10 days after their son Roman was born in December 2005. The baby cried nearly the entire time and continued to cry after his father went back to the Middle East.

At a postpartum checkup, she "just lost it." Her obstetrician referred her to the Colic Clinic, where clinicians diagnosed GER and put Roman on medicine, suggested ways to help Roman sleep without being held, and insisted she invest in her own health. "I started to go for bike rides. It was hard to leave him, but they told me I needed to find time for myself or I'd crack up," she says.

Now that Roman is a healthy toddler, Vickie feels both relieved that her child's colic is past and strengthened by her experience. "I enjoy him so much now, but I don't forget what we went through," she says. "Without the clinic, I really couldn't have done it."

Advice From The Colic Docs, p.5

The Infant Behavior, Cry and Sleep Clinic is the only place in the U.S. that treats colic exclusively and offers family-based treatment. For families who don't live near the Providence center, clinic director Barry Lester, Ph.D., offers the following strategies for identifying and coping with excessive crying, with the help of your child's pediatrician.

Keep a cry diary. For every 15 minutes of your baby's day and night, record whether she's fussing, crying, sleeping, eating, or awake. At the end of a week, highlight the five behaviors in different colors for a visual of how distressed your child actually is, when her good moments occur, and when she's most likely to be upset. This will help your child's doctors determine whether your baby suffers from colic.

Assess whether your baby has other colic symptoms. Does he have sudden crying episodes? Is his cry piercing? Does he react by clenching his hands or fists, arching his back, drawing up his knees, or holding his breath? Is he unable to be calmed? These are signs that your baby's crying may be outside the normal range and he may be in pain, Dr. Lester says.

Talk to your baby's doctor about potential feeding issues, including gastroesophageal reflux (GER) or intolerance to cow's-milk protein, and discuss a possible treatment like Zantac or another pediatric acid inhibitor, a switch to hypoallergenic formula, or changes to your diet if you're nursing. It may be worth asking for a referral to see a pediatric gastroenterologist, who can definitively diagnose GER or allergies. If your child has GER, try holding her upright for 20 to 30 minutes after feeding, using a wedge pillow, or propping up her crib mattress to minimize reflux. Consult with your child's pediatrician for the safest ways to accomplish this.

Stick to firm, consistent bedtime and nap routines. Put your child to sleep in the same place every time, make nighttime feedings all business, establish a soothing routine, and put the baby down to sleep drowsy but awake when possible.

Don't be afraid to take a break. Once the baby's physical needs are met, it's okay to leave her alone to cry for five to 10 minutes. This helps her develop self-soothing techniques.

Remember that the best kind of colic care treats parents' needs too. Leave your baby with a trusted caregiver and take time to talk with friends or professionals about what you're going through. The more parents of colicky babies take action, the less helpless they feel, Dr. Lester says.